Hey Dickhead, try getting infected and then tell me HIV doesn't cause Aids. Or better yet, watch a loved die, a slow death.............And then let's see if you post that HIV doesn't cause Aids. You don't become old with out living, and sure as hell don't get AIDS without HIV.

The other ACT UP has declared war on the entire AIDS community. Martin Delaney, a veteran of their violence, is mad as hell and he's not going to take it anymore.Stick 'Em Up: ACT UP/SF charges that AIDS is a fraud; now the group faces its own criminal changes.The April meeting was cosponsored by Project Inform (PI), the group I founded, and Survive AIDS, previously known as ACT UP/Golden Gate until they changed their name to avoid confusion with the notorious rowdies of ACT UP/San Francisco. Some 100 HIVers had crowded into the small community-meeting space, sucking up info about Strategic Treatment Interruptions (STIs). Suddenly, a commotion exploded in back. In a flash of waving signs, anyone familiar with the AIDS scene in our fair city knew what to expect: ACT UP/SF had arrived, announcing that "AIDS is over" and condemning those of us still working in the field as "murderers, liars and cheats." Then, shrieking like howler monkeys, they marched Brownshirt-style up to the speakers' table and began throwing fistfuls of large pills in our faces. San Francisco long ago lost patience with these clowns, who have violently disrupted AIDS events for almost a decade. Their escapades include pouring feces-and-urine-laden cat litter on San Francisco AIDS Foundation head Pat Christen, launching attacks on the Stop AIDS Project (a gay HIV prevention group), even crashing PI's annual fundraising dinner and overturning tables of PWAs. And they routinely ambush people on the street (often women from our staff), shoving, shouting and spitting. Such big, brave boys! We were all fed up, and at the STI forum, the audience was ready to rip off heads. When PI's Judy Leahy tried to intervene, she was knocked to the ground by David Pasquarelli, the group's self-appointed intellectual kingpin. Though he insists that the event didn't happen, photos, hospital records and police reports say otherwise. In May, charges of misdemeanor trespassing were finally brought against him and three other ACT UP/SFers; a restraining order was also issued, requiring them to stay 100 yards away from any PI staff. Has San Francisco gone nuts? Or is it just a few troublemakers who have taken root? Virtually all other AIDS activists have condemned violence, especially against PWAs. It's extremely unsettling to find oneself the object of ACT UP/SF's bloodcurdling hatred, as it's hard to know when they or their hangers-on might pull out a weapon in a frenzy. It makes you wonder: If they truly believe their enemies are murderers, where will the violence end? What motivates their terrorist tactics? They blame it on a general "censorship" of their "HIV-is-harmless, pharmaceutical-drugs-are-poison" mantra. This dangerous dalliance with Peter Duesberg has led them to collaborate with the likes of congress member Tom "Kill the Ryan White Act" Coburn and attack the "fraud" of funding for ASOs and research. How any sane mind can take such steps while thinking itself the savior of the gay community is a mystery. That science finds no merit in their HIV denial, that their AIDS-is-a-hoax position can only lead to more infections, that their "don't get tested, don't take treatment" message results in people getting sick and dying -- none of this seems to matter to them. Like many HIV denialists, they confuse the question of whether HIV causes AIDS with whether it has caused AIDS in themselves yet. Their HIV -- several claim to be positive -- may be behind their denial and their promotion of barebacking, reopening the baths and other dubious pursuits.The May 4 Bay Area Reporter announced that ACT UP/SF had purchased a corner-storefront, four-apartment building, financed by one Robert Leppo, who also contributes to Republican Party campaigns. A small ACT UP chapter buying real estate on Market Street in the Castro? While not illegal, it's at least hypocritical for a group that condemns everyone else as "AIDS, Inc." and claims the rest of us are getting rich off the epidemic. No other activist group owns an $800,000 property in a trust in its employees' names. But ACT UP/SF's antics aren't about activism or AIDS. Should these bullies spit on you, you wouldn't think they deserved tolerance. There's room for different opinions, strategies, even beliefs -- but not for violence against PWAs, disruption of others' work and homophobia (one of their war cries that night was "Die, you faggots!"). What PWAs need is a safe space and respect -- exactly what we've fought to get from the public and the government. It's ironic -- and very sad -- to close the second decade of AIDS defending ourselves against the enemy within when we've come so far in taming the enemy without.

When a steady stream of reports of improved health and decreasing death rates started to flood the media in 1996 and 1997, denialists like AZT: Poison by Prescription author John Lauritsen dismissed them as so much smoke and mirrors. In a March 1997 talk he attributed the apparent good news to the "psychological effect" of people with AIDS being "expected to have a Lazarus recovery" and to "the selective reporting of anecdotes."(1) He predicted that this house of cards would soon collapse, declaring, "I expect within the next half year or year we'll see a perfectly hideous crash, a die-off." But the die-off failed to materialize. The Centers for Disease Control and Prevention continued to log declines in AIDS deaths in 1997, 1998 and -- tentatively, as reporting may still be incomplete -- 1999.(2, 3) As it has become indisputable that the drop in AIDS deaths is real, other explanations have been put forth. In her book, What If Everything You Thought You Knew About AIDS Was Wrong?, Christine Maggiore suggests that "a more likely explanation for decreased deaths would be the change in the official AIDS definition adopted in 1993, which allows HIV positives with no symptoms or illness to be diagnosed with AIDS. Since 1993, more than half of all newly diagnosed AIDS cases are counted among people who are not sick." The logic behind this statement is unclear. If, as Maggiore argues, CD4 cell counts do not correlate with health or illness, then the 1993 addition of a CD4 count below 200 as an AIDS-defining condition has qualified some perfectly healthy people for an AIDS diagnosis. But giving otherwise healthy people an AIDS diagnosis would not necessarily affect either the number of people who had AIDS based on the old criteria or their survival prospects. If, as some charge, the drugs actually cause AIDS, it might even increase the number of AIDS deaths by encouraging healthy people to go on toxic regimens. In her book and on the Web site of Alive and Well AIDS Alternatives, Maggiore makes a second argument: "AIDS deaths began to decline in 1994, two years before the new 'AIDS cocktails' were made available for general use," and so shouldn't be credited with a trend that had already started.(4, 5) In fact, according to the U.S. Centers for Disease Control and Prevention (CDC), U.S. AIDS deaths rose from 45,271 in 1993 to 49,677 in 1994 and 49,992 in 1995. AIDS deaths dropped to 36,930 in 1996, 20,945 in 1997 and 16,432 in 1998, the lowest number since 1986.(3) A variation on this argument -- that the decline in AIDS deaths began well before the advent of HAART -- was put forth by Celia Farber in the March, 2000 issue of Gear. She quotes David Pasquarelli, of the group that calls itself ACT UP San Francisco, writing that his organization "recently unearthed a 1997 study by San Francisco Health Department director Dr. Mitch Katz which exposes a shocking statistic which would appear to dispel the claim that the cocktails have caused AIDS deaths to plummet. Using stored blood samples and computer analyses, the study, published in the Journal of AIDS and Human Retrovirology, concluded that new HIV-antibody positive diagnoses peaked in 1982 in San Francisco -- two years before AIDS even had a name." She notes that the study estimated new HIV infections in San Francisco at 500 per year from 1987 on, adding that "Katz has since confirmed the group interpreted his data correctly."(6) The study projected that reduced rates of HIV transmission would lead to fewer AIDS cases a decade later. But in announcing this "shocking" fact Farber never explains why she and Pasquarelli seem to fully accept estimates based on an assumption both have emphatically rejected: that HIV causes AIDS.(7) This also may be the only time ACT UP San Francisco has agreed with Katz, whom it accused of "genocide" in 1997 for studying post-exposure prophylaxis,(8) and more recently branded "a lying AIDS industry clown who pulls bogus HIV increases out of a hat in order to secure funding."(9) Farber's claim that Katz accepts ACT UP San Francisco's interpretation of his data is mistaken. The key conclusion, that reduced HIV transmission in the 1980s foreshadowed fewer AIDS cases in the 1990s, is stated explicitly in the article and requires no interpretation. Katz firmly disputes the claim that HAART has had no effect. The numbers of actual and projected AIDS cases -- not mentioned in Farber's article -- appear to back him up. Katz and colleagues, assuming that treatment would only be as effective as AZT monotherapy and adjusting for distortions caused by the 1993 change in the CDC AIDS definition, projected that the drop would level out beginning in 1995 with 1,283 new AIDS cases that year, 1,200 in 1996, 1,122 in 1997 and 1,115 in 1998.(7) But 1995 saw 1,743 AIDS cases, 40 percent above the projection. In 1996, the year protease-based combinations became the standard of care, new cases plunged to 1,178. They kept dropping to 899 in 1997 and 713 in 1998-more than a third below projected levels. "That," says Katz, "is the treatment effect."(10)

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It is worth noting that some in the denialist camp not only claim that anti-HIV treatment is worthless, but that it actually causes AIDS. The most well known of such theorists is University of California Berkeley molecular biologist Peter Duesberg, who has proposed that AIDS in the U.S. and Europe is caused entirely by recreational drugs and antiretroviral medications, especially AZT.(25, 26) Many in the denialist movement who do not fully embrace Duesberg's hypothesis agree that anti-HIV drugs play a role in causing AIDS. Maggiore, for example, accuses AZT of killing HIV patients and suggests that all of the nucleoside analogues may constitute "AIDS by prescription."(27) Pasquarelli recently asserted that "the ONLY people dying are those who take poisonous AIDS drugs."(28) (emphasis in original) Such theories are difficult to sustain in light of the data cited above, and the broader picture backs up the studies. During the period in which AIDS deaths dropped by two thirds, sales of the drugs condemned as "toxic DNA chain terminators" skyrocketed. Sales of Glaxo's antiretrovirals, led by AZT and 3TC, quadrupled between 1995 and 1999.(29) Bristol-Myers Squibb, the other leading maker of nucleoside drugs, also reported large sales increases.(30) Since Duesberg's "drug-AIDS hypothesis" pins much of the blame on recreational drugs, it is plausible that a massive decline in recreational drug use might have overcome the exponential growth in use of allegedly murderous antiretrovirals, but the opposite appears to have happened. The government's major instrument for measuring rates of drug use, the National Household Survey on Drug Abuse, charted an almost unbroken rise in the use of illegal drugs during the 1990s. The survey noted substantial increases in use of many of the specific drugs Duesberg implicates in AIDS, including heroin, cocaine and inhalants.(31) While information on drug use by gay men, still disproportionately affected by AIDS, is less complete, there has been much discussion in the gay press and in popular books about increasingly heavy drug use in certain segments of the gay community, particularly the co-called "party circuit." At least one study has reported significant increases in both numbers of drug users and severity of drug use among young gay men from 1994 to 1997.(32) Might it be that this increase in use of anti-HIV and recreational drugs hasn't had enough time to do damage? While theoretically possible, such a proposition would directly contradict the arguments Duesberg made throughout the 1990s. In making an epidemiological case for drugs as the cause of AIDS, he cited evidence that drug use -- as indicated by increases in drug-related arrests and hospital emergency room admissions -- had risen in tandem with AIDS cases during the 1980s.(25, 26) He has also argued that Kimberly Bergalis, famous for allegedly being infected with HIV by her dentist, was killed by AZT in just two years.(33) The arguments that once seemed to bolster the drug-AIDS hypothesis now severely undercut it. And the evidence overwhelming demonstrates that HAART has played a large role in reducing AIDS deaths in the last several years. This does not mean that antiretroviral drugs are benign or that their toxicities are not serious. Indeed, this and other HIV/AIDS publications have noted a growing movement away from the so-called "hit early and hard" approach precisely because the drugs now in use may well be too toxic for most patients to use indefinitely. There is much work to be done, both to develop new, safer treatments and to make better use of the ones we have. Indeed, one of the tragedies of the denialist movement is that it has distracted attention from these issues. By forcing researchers and activists to take time and energy defending what has already been proven, it has diverted effort from critical questions regarding what sort of research is needed and how to speed the development of better, less toxic therapies.

ISSN # 1052-4207 Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.

Certain localities have been able to assemble cohorts that reach essentially the entire population seeking care for HIV- or AIDS-related illness. For example, since 1986 the Canadian province of British Columbia has distributed anti-HIV drugs at no cost through a centralized system under specific guidelines, making tracking and analysis relatively simple.

In order to compare the real-world results of dual-nucleoside combinations vs. three-drug regimens including either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor, researchers at the British Columbia Centre for Excellence in HIV/AIDS studied all HIV-positive patients in the system who began anti-HIV treatment from October 1, 1994 through December 31, 1996. In a multivariate analysis (using statistical methods to adjust for a variety of differences between patients), those on two drugs were over three times as likely to die as those on three.(20)

San Francisco has an AIDS surveillance system that captures basic data for approximately 95 percent of the city's AIDS patients, and this data is particularly interesting in light of Farber's allegations. Unlike the study Farber cites, which used a complex collection of computer models and projections to estimate HIV infection rates and AIDS cases, this "active surveillance" system assembles data on actual patients from health care facilities, death certificates and other sources. An analysis of this information was published earlier this year in the American Journal of Epidemiology, with a year's worth of additional follow-up presented at the International AIDS Conference in Durban, South Africa (July 9-14, 2000).

The first report found that survival after an AIDS diagnosis improved dramatically for those diagnosed in 1995 and 1996 compared to earlier periods. Researchers then analyzed all deaths among San Franciscans diagnosed with AIDS from 1993 through 1996 for whom treatment and CD4 data was available, finding that any antiretroviral treatment, before or after an AIDS diagnosis, significantly reduced the risk of death. When protease inhibitors were included the risk of death was cut by 75 percent compared to no treatment. The analysis included deaths from all causes, so any deaths from drug toxicities were included.(21) The research team's Durban presentation extended the findings through 1997 and again found that "antiretroviral therapy, especially combined with a protease inhibitor, strongly predicts improved survival."(22)

A number of other presentations at Durban reported a similar association between HAART and reduced rates of death and illness. Dr. Gary Reiter of the River Valley HIV Clinic in Holyoke, Massachusetts presented an analysis of HIV patients seen at his clinic and another Holyoke facility from March 31, 1997 to December 31, 1999.

177 of 300 patients were on HAART, defined as any regimen that maintained HIV suppression below 25 copies. According to Reiter, baseline characteristics of HAART and non-HAART patients were similar, except that those not on therapy generally went untreated because of psychosocial instability, mental illness and/or substance abuse. 20 of 23 deaths were in the 123 non-HAART patients. None of the three HAART deaths were due to AIDS-related infections, but one was from a drug side effect: ddI-related pancreatitis.(22, 23)

Reiter, who began his career in San Francisco at the start of the AIDS epidemic, commented, "Those of us who've been involved with the epidemic since '81 know that antiretroviral therapy works. I had hundreds and hundreds of patients die in San Francisco (1981 to 1985) and then western Massachusetts (1987 to 1995) until we got effective therapy. We are coming up on four years now of no AIDS deaths in treated individuals."(24)

Even early skeptics about some of the mainstream ideas have seen the value of anti-HIV treatment. Joseph Sonnabend, M.D., who treated some of the first AIDS patients about 20 years ago and whose early articles are still quoted on some denialist Web sites, now says, "the antiviral therapies available since about 1996 can be life saving in people with more advanced disease, and HIV clearly plays a central role in this disease."

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This document was provided by AIDS Treatment News.http://www.thebody.com/atn/350/local.html

Still, the basic issue put forth by Farber, Pasquarelli and Maggiore needs to be answered: If some unknown factor or factors unrelated to treatment reduced the number of AIDS patients, HAART could be receiving undeserved credit for the drop in deaths. On the other hand, if it can be shown that HAART has substantially improved patients' survival it is at least partly responsible for the good news.

The critical question, then, is: Is there evidence that HAART has improved the survival of HIV/AIDS patients? According to a leading denialist, University of California chemist David Rasnick, "It may come as a surprise that there is not even one study in the vast scientific, medical literature that shows that . . . a group of HIV-positive adults or children who take the anti-HIV drugs live longer or better quality lives than a similar group of adults or children who are HIV-positive and do not take the drugs."(11) In fact there is an abundance of such evidence. Some, from clinical trials, has been discussed in detail in medical articles and at conferences. But clinical trials, conducted on limited numbers of patients for a relatively short time, with care often provided by physicians with more HIV expertise than average doctors, might not reflect what happens to most patients.

Real-world information on the impact of HAART in daily practice comes from what are known as cohort studies, which follow the experiences of specific groups of patients over extended periods of time. A number of large, prospective cohorts, specifically set up to track both the natural course of HIV infection and the effects of treatment and behavioral factors, have now reported results covering the pre- and post-HAART eras. Additionally, a number of individual hospitals and clinics have reported on the impact of HAART on their patients.

The results from these cohorts, covering tens of thousands of patients from a wide range of locations and backgrounds, have been astonishingly consistent despite differing methodologies: When HAART is introduced, opportunistic infections and deaths drop. Patients on anti-HIV therapy do better than those on no therapy, and those on regimens involving more drugs do better than those on fewer. Most of these analyses, by focusing on deaths among patients already diagnosed with AIDS, are not affected by any overall reduction in the number of AIDS cases, whether due to reduced HIV transmission or some unknown factor.

One of the world's largest AIDS cohorts is the CDC's Adult/Adolescent Spectrum of Disease Project. The ASD project began in 1990 and has enrolled over 49,000 participants at 93 hospitals and clinics in nine cities. As of January 1998, 19,565 had an AIDS diagnosis by the 1993 definition.

During that period 9,280 deaths were recorded, and researcher Amy McNaghten and colleagues included in their analysis all except 188 deaths caused by murder, suicide or drug overdose. Average survival time after diagnosis increased in the later years of the study, coinciding with a shift from monotherapy (a single antiretroviral, such as AZT alone, or ddI alone) to two-drug regimens, and later to three-drug HAART combinations. All anti-HIV regimens improved survival compared to no treatment, with more intensive regimens producing greater improvement. Patients on three-drug combinations had a 1.6 times lower risk of death than those on dual therapy and a 2.5 times lower risk of death than those on monotherapy.(12)

The ASD researchers later reported that incidence of AIDS- defining opportunistic infections in the whole study population of over 49,000 patients plummeted when HAART came into common use in 1996. Strikingly, 46 percent of PCP cases after 1996 occurred in people who had never been in HIV/AIDS care.(13)

One of the most-cited reports came from the HIV Outpatient Study, which has followed over 3,500 patients in eight U.S. cities since 1992. Researchers analyzed data for all who had ever had a CD4 count below 100 (considered most vulnerable for opportunistic infections or death) from 1994 through June, 1997. Use of protease-inhibitor-containing regimens among these 1,255 patients went from two percent in mid-1995 to 82 percent by June, 1997.

Mortality (deaths per 100 person-years) remained roughly constant in 1994 and 1995, then dropped abruptly in the second quarter of 1996 and continued dropping. To determine the effect of treatment, investigators classified patients by type of therapy: no antiretrovirals, nucleoside analogue monotherapy, nucleoside combination therapy, and combination therapy including a protease inhibitor. Patients on no anti-HIV treatment were 1.5 times as likely to die as those on monotherapy, 2.9 times as likely to die as those taking combination nucleosides and 4.5 times as likely to die as those on protease inhibitor combinations. The risk of serious opportunistic infections was reduced in a nearly identical pattern.(14)

Strikingly similar results were reported by the EuroSIDA cohort, a prospective observational cohort that began recruiting patients from across Europe in May 1994. In November 1998 researchers reported on all 4,270 patients enrolled who were over age 16 and had a CD4 count below 500. Through March 1998, 1,215 had died.

As in the HIV Outpatient Study, the death rate was analyzed by treatment category. The results, published in The Lancet, are broken down into six-month periods, and the correlation between more intensive regimens and fewer deaths is consistent and dramatic. The lowest death rate recorded in any period for patients on no treatment was 50.3 per 100 person-years, while for those on one antiretroviral the death rate never rose above 22.3 per 100 person-years. On two drugs deaths never rose above 7.9 per 100 person years and on three or more drugs the highest rate recorded was 3.9 per 100 person-years. In other words, the lowest death rate for patients on no anti-HIV drugs was 13 times the highest death rate recorded for those on three or more. The researchers further noted that "in any given 6-month period, the death rate among patients taking protease inhibitors was much lower than among those not taking protease inhibitors."(15)

The EuroSIDA researchers also examined opportunistic infection incidence for HAART and non-HAART patients. Patients with CD4 counts below 200 were over three times as likely to have an opportunistic infection if they weren't on HAART.(16) Several other large European cohorts have reported similar results, including the Swiss HIV Cohort,(17) the Italian HIV Seroconverter Study(18) and the Italian Register for HIV Infection in Children.(19)

ISSN # 1052-4207 Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.

This document was provided by AIDS Treatment News.http://www.thebody.com/atn/350/cohort.html

Note: AIDS Treatment News has published a series of articles looking in depth at some of the bizarre ideas about AIDS, theories which are being used to persuade people to change or completely stop their medical treatment, or to ignore precautions for preventing HIV infection. One of the most bizarre is that the epidemic does not exist but is just a new name for a collection of old diseases. AIDS writer Bruce Mirken analyzes this claim and similar theories that have also been widely promoted. -- John S. James] The AIDS denialists, who dispute not only the role of HIV in AIDS but nearly all scientific knowledge about the epidemic, regularly claim that the very notion of AIDS as a distinct medical condition is a mistake. What medicine has identified as a major epidemic, they insist is nothing of the sort.

A number of variations on this theme have been put forth. Some have argued that AIDS is nothing but a "group fantasy" or "epidemic hysteria."(1) Others claim that several separate but real medical problems have been wrongly lumped together. ACT UP San Francisco has repeatedly claimed that "AIDS is over," suggesting that it did exist at one time but has somehow come to an end.

While most in the denialist camp accept some physical cause or causes for the illness we call AIDS, they claim science has fundamentally misunderstood what is going on, leading to faulty conclusions about causation. "AIDS by definition is not new and is not a disease," the web site of HEAL Toronto declares. "AIDS is a new name for 29 old illnesses and conditions, including yeast infections, diarrhea, pneumonia, cancer and tuberculosis."(2) Christine Maggiore of the Los Angeles group Alive and Well adds that "every AIDS indicator disease occurs among people who test HIV negative," existed prior to AIDS, and has "medically proven causes that do not involve HIV."(3)

AIDS, in this view, is just a new name given to these old diseases when they occur in people who test positive for HIV antibodies. Furthermore, it is claimed that inclusion of a positive HIV test in the criteria for an AIDS diagnosis has created a phony connection between these illnesses and HIV: "Pneumonia + positive HIV test = AIDS," Maggiore writes, but "Pneumonia + negative HIV test = pneumonia," thus creating "the illusion of a perfect correlation."(4)

Though factually wrong, such statements appear regularly in denialist literature. Another complaint is that the number of AIDS cases has been artificially increased by repeated changes in the official AIDS definition. Adding more conditions to the definition, it is argued, pumps up the number of cases even though those new cases may not even be ill.(2, 4)

What Was New in 1981?

The notion that AIDS is simply "a new name for old diseases" requires ignoring years of history and reams of published medical data. The official start of the AIDS epidemic dates from mid-1981, when the U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report described cases of Kaposi's sarcoma (KS) and Pneumocystis carinii pneumonia (PCP) in young, previously healthy gay men.(5, 6) Detailed reports of these and other cases, a few involving heterosexual drug injectors, were published in several medical journals later that year.

Prior to 1980 KS and PCP were extraordinarily rare in the U.S. Annual incidence of KS ranged from 2.1 to 6.1 cases for every 10 million people,(7) usually occurring in older men of European descent. The disease generally progressed slowly, with an average survival time of 8-13 years.(7, 8) PCP was nearly as rare, and the drug used to treat it, pentamidine isothionate, could only be obtained through the CDC's Parasitic Disease Drug Service, which kept detailed statistics. Strictly a disease of people with weakened immunity due to disease, cancer chemotherapy or immune-suppressive treatment for organ transplantation, PCP had "never been convincingly demonstrated to occur in an immunologically normal adult."(9) In one study, 98 percent of patients had known immune defects, and the others were all seriously ill infants. Even though most were quite sick even before their PCP, the disease often responded well to treatment and relapses were rare.(10)

These new PCP and KS cases shattered the pattern. Most patients were young men, often in their 20s and 30s, with no identifiable reason for weakened immunity. Their KS was "fulminant, malignant"(8) and rapidly progressing. Some had both PCP and KS, and most had a cluster of other problems including persistent fever, weight loss, swollen lymph nodes, and other infections usually associated with weakened immunity, including cytomegalovirus and toxoplasmosis. This unremitting barrage set victims on a downward spiral that commonly ended in death within a year.(5, 6, 8, 9, 11, 12, 13, 14)

This onslaught of infections in people with no known reason for being sick was so unusual that the usually reserved British journal The Lancet called it "bizarre" twice in one brief commentary.(15) Patients also showed unexplained weakness in their immune responses, with a consistent pattern of defects in their cellular immunity.(5, 6, 8, 9, 11, 12)

The physicians treating these patients had no doubt they were seeing a new clinical syndrome ("syndrome" is the medical term for a group of signs or symptoms that appear together and indicate a particular condition). And these doctors weren't babes in the woods. Several treated large numbers of gay men living a "fast lane" existence including multiple sex partners and recreational drugs, while others worked at urban hospitals treating many drug addicts, yet none of them had seen anything like this.(16)

The Evolving Definition of AIDS

As with any new syndrome, scientists' understanding of AIDS evolved gradually, with the most obvious and severe manifestations noticed first and rarer or subtler ones recognized later. A careful review of how the CDC has defined a case of AIDS contradicts the cartoon version presented by the denialists and shows that the definition has evolved cautiously -- perhaps too cautiously at times.

(For simplicity this analysis will focus on the CDC's AIDS case definition. While not followed universally, health authorities in other industrialized countries often use the CDC's work as a starting point. The enormous subject of AIDS in Africa and other third world areas requires a separate article.)

The CDC first published an AIDS case definition in September, 1982. AIDS was simply defined as "a disease, at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease." Thirteen specific diseases were listed.(17)

HIV (then known as HTLV-III or LAV) was discovered in 1984, but the CDC waited a full year, until after a discussion at the Conference of State and Territorial Epidemiologists, before revising the AIDS definition. This new definition added a small number of conditions which would be considered AIDS-defining if they occurred in a person with a positive HIV test. But the original list of infections still triggered an AIDS diagnosis without an HIV test if they occurred in a person with depleted CD4 (T-helper) cells and no known reason for immune dysfunction.(18)

It was soon clear that patients commonly experienced a much broader array of illnesses than the indicator diseases listed by the CDC. In 1987, the agency noted, "It became apparent that some progressive, seriously disabling, even fatal conditions (e.g. encephalopathy, wasting syndrome) affecting a substantial number of HIV-infected patients were not subject to epidemiological surveillance, as they were not included in the AIDS case definition." So the agency made another cautious revision, with encephalopathy (dementia) and wasting syndrome being the most notable additions to the list of indicator conditions.(19)

But the CDC's AIDS definition was still capturing only a narrow piece of the picture, and not always the most severe piece. "There are very many people who are very ill who don't have AIDS by the CDC definition," said Los Angeles AIDS specialist Scott Hitt, M.D. (who went on to head President Clinton's AIDS Council) in 1990. "There are also people with one KS lesion (qualifying them for an AIDS diagnosis) who are doing very well."(20)

Part of the problem was that the only opportunistic infections that made it into the CDC's database were whatever conditions triggered a patient's initial diagnosis. CDC spokespeople acknowledged they simply didn't have the means to track the rest.(20) Pressure mounted on the agency to adopt a definition that was more reflective of the real-world clinical experience of the most seriously ill patients, and after a lengthy period of discussion and debate, the current definition went into effect in January, 1993. For the first time it allowed an AIDS diagnosis based purely on an immune system measure: a CD4 cell count below 200 or a CD4 percentage below 14. Based on strong epidemiological evidence, three conditions were also added as AIDS indicator diseases in people with HIV: invasive cervical cancer, pulmonary tuberculosis and recurrent pneumonia (defined as two or more episodes within one year).(21)

One thing did not change: The core list of 12 opportunistic infections -- PCP, toxoplasmosis, etc. -- that dated from the mid-1980s would still trigger an AIDS diagnosis even without a positive HIV test.(21, 22) In other words -- and contrary to the denialists' claims -- a positive HIV test has never been required to diagnose AIDS in people with these otherwise rare illnesses. At this point it is useful to refer again to Maggiore's version of the AIDS definition, variations of which appear throughout denialist literature: "Pneumonia + positive HIV test = AIDS," but "pneumonia + negative HIV test = pneumonia." In fact, pneumocystis pneumonia triggers an AIDS diagnosis regardless of HIV status, and in HIV-positive persons, more conventional bacterial and viral pneumonias do not automatically trigger an AIDS diagnosis. To qualify as AIDS they must happen at least twice within a year, because only such multiple episodes are strongly associated with immune suppression.(21) Simply put, the "illusory correlation" so harped on by the denialists is an illusion of their own invention.

Another favorite denialist complaint is that some of the toxicities of certain AIDS drugs match items in the list of AIDS-defining conditions. As with the assertions discussed above, this claim is based on a skewed and often blatantly inaccurate reading of the case definition. In any case, the list of toxicities often cited as "AIDS by prescription"(23) consists entirely of conditions whose association with HIV was well established before AZT and other antiretrovirals came into widespread use.

Duesberg's Epidemiology and Other Mysteries

A related but distinct thesis has been advanced by University of California Berkeley Prof. Peter Duesberg: AIDS is in fact several separate epidemics lumped together. Proof, he and colleague David Rasnick suggest, lies in the fact that members of different risk groups get different diseases. KS, he notes, is seen mostly in gay men, while "weight loss and tuberculosis predominate in intravenous drug users, and pneumonia and candidiasis are almost the only two of the 30 AIDS-defining diseases that are diagnosed in hemophiliacs."(24)

These "distinct, subepidemic-specific diseases," Duesberg and Rasnick argue, rule out a common cause, infectious or otherwise. They further insist that AIDS indicator conditions can be divided into those that are immune deficiency-related, like PCP, and those that aren't, such as KS. A significant proportion of AIDS cases, they note, are diagnosed based on these "non immune deficiency diseases."(24)

Duesberg's reading of the literature is, to put it gently, selective. For one thing, despite his repeated assertions to the contrary, an association between KS and weakened immunity had been well established in the medical literature prior to AIDS.(7) As for his claims about differing opportunistic infections in different risk groups, it is hardly a surprise that populations with widely varying behaviors, lifestyles and health risks would experience severe immune deficiency somewhat differently, and such differences have indeed been noted. But even a cursory glance at the medical literature quickly dynamites Duesberg's claim that these differences are so dramatic as to constitute separate epidemics. For example, five years before Duesberg and Rasnick's assertion that pneumonia and candidiasis are "almost the only two" AIDS-defining conditions seen in hemophiliacs, a European hemophiliac cohort found that of 37 diagnosed with AIDS, 6 had toxoplasmosis, 3 had wasting syndrome, 3 had dementia, 2 had MAC, 1 had CMV and 1 had lymphoma as their AIDS-diagnosing illness.(25)

The same Duesberg/Rasnick article touts both the "drug-AIDS hypothesis" and the "new name for old diseases" theory with an impressive list of references purportedly showing that AIDS-defining illnesses had been widely identified in drug users prior to and without AIDS. Duesberg's chart has at times been borrowed by other denialists.(24, 26) But again his "evidence" wilts under close examination. For example, one reference he cites repeatedly -- as evidence that immune deficiency, candidiasis, lymphadenopathy and weight loss had been documented in heroin addicts pre-AIDS -- is a 1973 article by Pillari and Narus from the American Journal of Nursing. But the article, it turns out, isn't a study but simply an anecdotal description of patients seen in one treatment program. It gives neither numbers of cases nor occurrence rates for any of the conditions described.(27) In fact, Pillari and Narus specifically mention just one of the four conditions Duesberg attributes to them, lymphadenopathy. Candidiasis is perhaps implied by nonspecific references to "fungal infections," while immune deficiency and weight loss are implied even more vaguely and indirectly. And although Duesberg's chart lists all four conditions as "AIDS defining," nothing in the article comes remotely close to describing an illness that would meet the criteria for an AIDS diagnosis.(27) Finally, a different spin has been put out by ACT UP San Francisco. Some of their materials echo the general denialist notion that the whole epidemic is a scam, but their most-repeated phrase in recent years has been, "AIDS is over." Such statements often refer to declining numbers of AIDS cases and deaths.(28) But extensive evidence links those declines to improved anti-HIV treatment (for more on this see AIDS Treatment News' special issue, "Treatment and Survival," Sept. 8, 2000). And for the families of the 10,198 people who died of AIDS during 1999 according to the most recent CDC figures,(29) AIDS is certainly not over.

References

1. Schmidt, Casper G., "The group-fantasy origins of AIDS," in The AIDS Cult, edited by John Lauritsen and Ian Young, Asklepios USA, 1997.

From AIDS Survival ProjectA coalition of people affected by HIVSeptember, 2000

Along the Latex Highway -- Queens of DenialBy David Salyer

Last February the members of ACT UP Golden Gate voted to change its name to "Survive AIDS!" They changed their name to put an end to growing confusion in the community between ACT UP Golden Gate and a group of people using the name "ACT UP San Francisco." A little background history is needed to set the context for this decision. ACT UP (AIDS Coalition to Unleash Power) began in 1987 in New York City, and was the foundation of the AIDS direct action movement and a catalyst for changing the way the public, the medical establishment, and the government responded to the AIDS crisis. Using direct action and civil disobedience, ACT UP chapters throughout the country made enormous strides for patients rights.

In San Francisco, ACT UP Golden Gate split from the original ACT UP San Francisco in 1990. ACT UP Golden Gate concentrated on issues involving treatment and treatment access, while ACT UP San Francisco focused on broader social issues involving public policy and politics. Over the next several years the two ACT UP chapters worked separately or together on local and national AIDS issues.

By the late '90s, ACT UP San Francisco developed a very different philosophy concerning AIDS treatment and began to align itself with groups that believe HIV does not cause AIDS and that it is the use of anti-HIV medications which make people get sick and die. ACT UP San Francisco members are now called "AIDS dissidents" because of views like these: antiretroviral drugs are harmful; safer sex is unnecessary; animal testing of medical therapies is unethical; HIV is not the cause of AIDS.

As you might guess, ACT UP San Francisco's views have led to frequent and sometimes violent conflicts with other activists, AIDS service organizations and medical researchers. ACT UP San Francisco's targets have included national ACT UP founder Larry Kramer and the Bay Area's other ACT UP group, ACT UP Golden Gate, which accepts the theory that HIV causes AIDS. ACT UP SF has outraged lots of people in the gay and AIDS communities. Like when ACT UP SF member Ronnie Burk dumped used cat litter onto the head of San Francisco AIDS Foundation Executive Director Pat Christen at a public forum in 1996.

Not surprisingly, ACT UP SF's tactics have mostly undermined their credibility, but they continue to spread their message by posting flyers, spray-painting sidewalks, placing newspaper advertisements urging people to "challenge the HIV myth," and holding community forums with titles like "Rethinking AIDS: From Tragedy to Triumph," that sometimes draw as many as 90 people and typically consist of a panel of so-called experts (discredited scientists, researchers or doctors who share the common belief that "the collection of illnesses grouped together and called AIDS is not caused by a virus.")

Although ACT UP SF is the most visible group of dissidents, other groups (some with overlapping memberships) also question the authenticity of AIDS. These groups include ACT UP Hollywood, HEAL San Francisco, and Alive and Well, formerly known as HEAL Los Angeles. Members of these groups have claimed that the AIDS epidemic is over -- if indeed it ever existed -- and that the world would be better off if people stopped using protease inhibitors and other HIV medications. Disagree with them and run the risk of being shouted down, intimidated and driven out of the group. With the original ACT UP mission destroyed and abandoned, long-term members have been forced to move along, regroup or mutate into other organizations like ACT UP Golden Gate's "Survive AIDS!"

So often, it's easy for us to say, "Oh, those crazy California folks!" After all, isn't this the same state that gave us the Manson Family, the Unabomber, the O.J. trial and the Heaven's Gate cult (whose 39 members committed mass suicide in March 1997, believing their spirits would join a UFO trailing the Hale-Bopp comet)? Well, AIDS dissidents aren't just a bizarre quirk of California activism anymore.

On the opposite coast, the latest incarnation of ACT UP Atlanta has begun its very own public gutting of that chapter's original mission. Looking for examples between the "old" ACT UP Atlanta and the "new" one? ACT UP Atlanta was formed in 1988, organized dozens of protests and highly publicized actions at institutions like the Centers for Disease Control and the state capital in an effort to raise awareness about AIDS and the need for funding, education and faster research. The "new" ACT UP Atlanta has aligned itself with the AIDS dissident groups in San Francisco and Hollywood (who explicitly state they believe HIV does not cause AIDS and is not a health emergency) and signed onto an ad placed in the Congressional Record in June calling on Congress to cut all funding for AIDS programs.

It saddens me to observe the decline and utter bastardization of ACT UP Atlanta. Several of its original members are friends and acquaintances of mine and have publicly denounced this current manifestation. This new ACT UP Atlanta is not improved, not progressive and certainly not worthy of its predecessor's deserved reputation for aggressive advocacy. In fact, the new ACT UP could do us all a favor and simply SHUT UP. All these dissident chapters of ACT UP are about as effective at convincing us that HIV does not cause AIDS as the National Rifle Association is at persuading us that we don't have a gun problem in this country. This really isn't about dissension at all; it's about denial. These people are in rabid, certifiable denial. They are, in fact, rebels without a clue.

Some basic research, like reading, provides ample evidence that AIDS is caused by the human immunodeficiency virus (HIV). Check out: www.niaid.nih.gov/factsheets/evidhiv.htm or hivinsite.ucsf.edu/social/spotlight/2098.3cce.html. It's there. Now take a look at dissident claims that "the use of anti-HIV medications make people get sick and die." I can respond to this bit of absurdist nonsense from my own personal history. I was infected with HIV in 1993. I took no drugs whatsoever (not AZT, not a single prophylaxis) from the time I seroconverted, until August 4, 1997, when I was hospitalized with 81 T-cells and a kick-ass case of pneumocystis pneumonia. At that time I was given Bactrim, a common antibiotic. I did not begin HIV drug therapy until almost two months later. I developed AIDS and almost died before I ever put an HIV-related drug in my body. I sit here now in front of a computer keyboard, with lots of HIV medications and various prophylactic treatments coursing through my veins, living proof that the dissident theory is a loopy pile of "X-Files" conspiracy crap.

All social movements evolve over time, and the AIDS movement has been through some dramatic transformations. ACT UP used to have a simple mission: help people survive with HIV until there is a cure. The tragedy here is that AIDS dissidents have such problems grasping the basics. HIV is an ugly fact of life, yet they appear to believe they can shout or intimidate it out of existence by denying its presence in mankind. I'm embarrassed for these half-baked loudmouths, because they are the AIDS community's equivalent of all those pathetic, public irritants who end up as guests on the "Jerry Springer" show.

This article has been provided by AIDS Survival Project.http://www.thebody.com/asp/sept00/latex.html

Over 5,000 scientists from around the world have signed the "Durban Declaration" affirming that HIV is the cause of AIDS. The list includes 11 Nobel Prize winners, as well as directors of leading research institutes and presidents of academies and medical societies, including the U.S. National Academy of Sciences, the Royal Society of London, the UK Academy of Medical Sciences, the Pasteur Institute, Max Planck Institutes, the U.S. Institute of Medicine, the European Molecular Biology Organization, the AIDS Society of India, the National Institute for Virology in South Africa, and the Southern African HIV Clinicians Society. The Durban Declaration will be published July 6, 2000 in Nature, which is widely considered the world's most prestigious scientific journal. According to Nature, "Signatories are of M.D. or Ph.D. level or equivalent, although scientists working for commercial companies were asked not to sign."

The complete text of the Durban Declaration, the list of signers, and the committee of more than 250 scientists who put it together are available at http://www.nature.com. Also, the Durban Declaration has its own Web site, http://www.durbandeclaration.org, including translations of the declaration into different languages.

From the Durban Declaration: The evidence that AIDS is caused by HIV-1 or HIV-2 is clear-cut, exhaustive and unambiguous, meeting the highest standards of science. The data fulfill exactly the same criteria as for other viral diseases, such as polio, measles and smallpox:

* Patients with acquired immune deficiency syndrome, regardless of where they live, are infected with HIV.

* If not treated, most people with HIV infection show signs of AIDS within 5-10 years. HIV infection is identified in blood by detecting antibodies, gene sequences or viral isolation. These tests are as reliable as any used for detecting other virus infections.

* People who receive HIV-contaminated blood or blood products develop AIDS, whereas those who receive untainted or screened blood do not.

* Most children who develop AIDS are born to HIV-infected mothers. The higher the viral load in the mother, the greater the risk of the child becoming infected.

* In the laboratory, HIV infects the exact type of white blood cell (CD4 lymphocytes) that becomes depleted in people with AIDS.

* Drugs that block HIV replication in the test tube also reduce viral load in people and delay progression to AIDS. Where available, treatment has reduced AIDS mortality by more than 80%.

According to a July 2 article in The Washington Post, officials and researchers working for the U.S. government were told not to sign an early draft of the declaration which circulated before South African President Mbeki's U.S. visit several weeks ago. After the visit several did sign, including Helene Gayle, head of the AIDS office of the U.S. Centers for Disease Control and Prevention. One who did not sign was Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases of the U.S. National Institutes of Health. His explanation was quoted as follows in The Washington Post: "I think in a backhanded way it gives them [AIDS doubters] greater credibility. It's sort of like a bunch of people saying the Earth is flat, and then you have to get everyone in the aerospace world to say that the Earth is round. That's crazy."

Also according to the Post, the Durban Declaration "was conceived in April by Peter Hale, an editor with the AIDS Research Alliance in Los Angeles, and a handful of American and European AIDS researchers. The group ultimately enlisted an 'organizing committee' of 265 scientists and physicians, including three Nobel laureates. Among the many African members is M.W. Makgoba, the head of the Medical Research Council of South Africa, the equivalent of the [U.S.] National Institutes of Health."

The U.S. National Institute of Allergy and Infectious Diseases maintains a Web page of links to information on HIV and AIDS. It is at: http://www.niaid.nih.gov/spotlight/hiv00/default.htm.

An important article in the July 5, 2000 Village Voice, "Proof Positive," by Mark Schoofs (who recently won a Pulitzer Prize for his reporting on AIDS in Africa) reports on the contribution of African scientists to showing that HIV causes AIDS. It is available at: http://www.thebody.com/schoofs/proof.html.

ISSN # 1052-4207 Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.

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